PHYSICAL EXAMINATION

Due to the relatively low number of high-quality studies and the inconsistent findings between the studies, the strength of the recommendation has been downgraded one level to moderate.

There were four high quality (Goossen, 2015; Porter, 2021; Shantanu, 2021; Syal, 2015) and eight moderate quality (Dhillon, 1985; Imran, 2019; Konan, 2009; Madhusudhan, 2008; Muellner, 1997; Mohan, 2007; Orlando Junior, 2015; Yaseen, 2019) studies that assessed the effectiveness of physical examination in the diagnosis of meniscus tears.

Physical examination is important in the assessment of patients with suspected meniscal injury. Various tests have been described including joint line tenderness, presence of effusion, range of motion, and meniscal provocative maneuvers such as the McMurray, Apley and Thessaly tests.

Goossen et al. studied the Thessaly test alone or when combined with the McMurray test and found similar sensitivity and specificity for the Thessaly test when performed in isolation (64% and 53%, respectively) and when the Thessaly and McMurray tests were performed together (53% and 62%, respectively). Syal et. al. compared a combination of tests including joint line tenderness, McMurray’s and Apley’s tests, with arthroscopic findings to evaluate for isolated meniscal injury and demonstrated a sensitivity and specificity of 75% and 94% respectively for medial meniscus tears and 38% and 100% respectively for lateral meniscus tears. Porter et. al. compared clinical assessment (joint-line tenderness, McMurray’s, and presence of effusion) and showed that clinical assessment was more accurate than MRI for diagnosing lateral meniscus tears (P<0.001) and similar to MRI for diagnosing medial meniscus tears (P=0.12), with arthroscopy being used as the reference standard.

The original publication of the Thessaly test by Karachalios et. al. showed a diagnostic accuracy of 94% and 96% respectively for the diagnosis of medial and lateral meniscus tears, which was higher than joint line tenderness, the McMurray test and the Apley test. This study was not included in the articles used to determine the recommendation as it did not meet clinical practice guideline inclusion criteria.

Benefits/Harms of Implementation
Physical examination will assist clinicians with assessing for the presence of meniscus tears and other knee injuries. There are no known risks from a comprehensive physical examination.

Outcome Importance
The four high quality and eight moderate quality studies demonstrate the importance of physical examination in the diagnosis of meniscus tears, although there is variability in the diagnostic accuracy of individual tests.

Cost Effectiveness/Resource Utilization
A comprehensive physical exam is a low-cost method for assessing patients for meniscus tears.

Acceptability
Physical examination should have high acceptability as it is routinely performed.

Feasibility
Physical examination is a feasible and expected component to evaluating patients for meniscal injury.

Future Research
Future research could determine the most useful and accurate examination maneuver or combination of examination maneuvers for diagnosing patients with meniscal injury.

Additional References
1. Karachalios, T. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005;87(5):955-62. PMID: 15866956.